You're Going To Love This!

First Name:

Last Name:

Date of Birth:

Email Address:

Current Physical Condition:

Primary Goals:

Area of Interest:

• 0: Complete inability to do any physical effort beyond walking with assistance
• 1: Ability to walk but may need help standing from a seated position
• 2: Can walk and stand without assistance and lift small objects from elevated positions like a can of vegetables from a table
• 3: Highly mobile and can lift small objects from the floor and place them above your head
• 4: Highly mobile and have no problem lifting 20 pounds from the floor and placing it above your head
• 5: Can lift a 50 pound object from the floor, carry it 10 feet, and place it on a table
• 6: Can lift a 50 pound object from the floor, carry it 100 feet, and raise it above your head
• 7: Can lift heavy objects multiple times and can sprint 40 feet without getting winded
• 8: Can lift heavy objects multiple times, ride a bike uphill for 30 seconds without getting winded
• 9: Lift very heavy objects multiple times, carry heavy objects 100+ feet, ride a bike on hilly terrain for long periods of time
• 10: Basically you feel like you can fly